Wheelchairs & Funding

Ultralight Update: The Demise of K0009

With the Manual Chair Miscellaneous Code Eliminated This Month, Industry Experts Worry About Access

Ultralight Update: The Demise of K0009This month, following previous postponements and multiple industry meetings with Centers for Medicare & Medicaid Services (CMS) personnel that were ultimately futile, the K0009 HCPCS code officially died.

Defined as “Other manual wheelchair/base,” K0009 for many years had worked as a miscellaneous code for manual chairs that due to certain characteristics or functions did not appropriately fit into another manual chair code.

Last year, CMS announced it was re-examining and recoding all K0009 products. CGS Administrators, the Jurisdiction C DME MAC, said in a message echoed by the other DME MACs: “Manufacturers ,will be required to submit a new coding verification application to the PDAC for review and assignment of the correct code for products currently coded as K0009.”

With that decision, CMS was essentially indicating it wanted to clean K0009’s house.

Same Code, Very Different Levels of Function

Currently, there are 64 power mobility HCPCS codes for power-operated vehicles (aka, scooters) and power wheelchairs.

But for the last 20 years, the industry has been working with a relative handful of manual chair codes, all introduced in 1993:

  • K0001: Standard
  • K0002: Standard hemi
  • K0003: Lightweight
  • K0004: High strength/lightweight
  • K0005: Ultralightweight
  • K0006: Heavy duty
  • K0007: Extra heavy duty
  • K0009: Other manual/wheelchair base

Not surprisingly, in the last 20 years, new technology — new materials, new ways of working with them, clinical research on subjects such as optimal propulsion methods, even the escalating numbers of bariatric patients — has resulted in chairs with innovative new functions. But with the elimination of the K0009 code, manufacturers are now forced to place their chairs into other codes.

Some K0009 chairs will, as of this month, become K0005 chairs. That means not just more chairs in the K0005 code, but more disparity among K0005 off erings, as well.

“When you look at a K0005 code today,” says Rita Hostak, VP of government affairs for Sunrise Medical, “the range of features and functions in that code is unbelievable — and to think that it’s all at one level of reimbursement is just astounding to me.

“You can have something that’s so very basic in that code that truly would not meet the needs of the majority of individuals with spinal cord injuries, all the way up now to very custom made-to-measure product — and it’s all at the same price. Where can you go on the open market and say, ‘I want the highest-featured, most functional product that you carry, but I want to pay the same price as I would for the least functional, least durable product you carry?’”

Given that K0005 chairs — including ones that used to be K0009 coded — have the same allowables, and given that profit margins for suppliers are so slender to start with, Hostak points out that suppliers will be financially motivated to choose less expensive K0005s that will net them more profit.

“CMS almost sets the program up to incentivize putting out the least-featured product,” she says. “Because why not? The supplier is going to get the same level of reimbursement.”

Josh Anderson, VP of product & brand management for TiLite, has a C5/C6 spinal cord injury. He’s 6'9" tall, self-propels a TiLite chair that’s coded K0009, and is the perfect example of a consumer who doesn’t fall within “average” consumer demographics.

In a March meeting in Baltimore with Center for Medicare Deputy Administrator & Director Jonathan Blum, Anderson says, “I was sitting right next to him. That was actually one of the reasons I went: The chair that I use cannot be duplicated as a K0005. We talked through all the measurements, how it aff ects my ability to get around. He looked right at me and seemed to understand what we were saying. All for naught. Frankly, it seemed like they made the decision a year ago.”

The Definitions of Custom

David Lippes, CEO/chairman of TiLite, said one of the justifications for in essence getting rid of the K0009 code centers on differing definitions of the term “custom.”

“I think I understand their thought process,” he says. “I don’t agree with it, but I think I understand it. CMS decided they had a pricing problem, not a coding problem, and this problem related to their understanding of the word ‘custom.’ Basically, only a custom product can be paid for under individual consideration based on MSRP, as opposed to having a fixed fee schedule associated with it. And with respect to a made-to-measure product like TiLite, we are custom. There’s a Congressional statute as to the definition of custom, and we fit it. There is a Medicare definition that they wrote that does not match the statute definition — and it’s that regulation they’re following, which we think is in error. “

Hostak says Sunrise faces a similar scenario with its Quickie Q7 active rigid chair: “Because it’s a custom-manufactured chair too, that product was coded K0009, and it now as of June 1 will be in the K0005 code. So we have a similar situation as TiLite because [the K0009 code] was based on it being custom. It was the custom process, that each one of these chairs is built one-off for the person based on those measurements.”

Lippes says the differing definitions for “custom” impacted other products in the K0009 category as well. While K0009 is often thought of as a “custom ultralightweight chair” code, prior to June 1 the code also included standing chairs, chairs with specialized tilt, and bariatric chairs with tilt.

“Basically all these products — they’re getting paid for based on individual consideration,” Lippes says. “I don’t know why [CMS is] worried about this now and hasn’t been for the last 10 years, but they decided that these products can’t be paid for under individual consideration, and therefore they had no choice but to stick them in other codes.

“And we said OK, if you can’t pay for them that way — and we’re not sure at least when it comes to made-to-measure that you can’t — then let’s build some codes to reflect the technologies, because there are all these reasons why these are unique from a clinical standpoint and a technology standpoint.

“After all, codes are developed for the purpose of segregating technology based upon clinical indications. So the Clinician Task Force spent literally hundreds of hours developing a 600-page report that provided evidence of the specialized nature, application and benefits of K0009-coded products. Based on this report, we asked CMS to work with us to develop these new codes. This, in effect, was our compromise — let’s build new codes that reflect the technologies that have been developed over the last 20 years, and you (CMS), in turn, can resolve your pricing concern on a code-by-code basis. That, in my mind, would have been a balancing of interests.

“But CMS refused. Instead, they solved a pricing concern through coding. It’s poor logic.”

Anticipating Access Problems

Lippes was a member of the work group — which included members of NCART, NRRTS and the Clinician Task Force — that met repeatedly with CMS over the K0009 issue.

Consumer access was another one of the topics that came up in relation to eliminating the K0009 code.

Hostak, who was also part of the K0009 work group, says, “We heard this from CMS staff when we were talking about the K0009 problems: ‘I hear you saying that if we take your product out of the K0009 code and we put it in this other code, that we’re going to create an access problem. I have people in my office every week saying, “If you reduce my reimbursement, there’s going to be an access problem.” My experience is I reduce the reimbursement and guess what: There’s not an access problem. So I’m having a hard time sitting here in this meeting and hearing you say there’s going to be an access problem when history tells me that’s just not going to be the case.’”

But Hostak is concerned that access will be jeopardized.

“Speaking for Sunrise, we have a bariatric product that’s intended, to accommodate patients with a weight up to 650 lbs.,” she says. “But it has rear-wheel adjustability, it has features and functions that are more like a K0005 wheelchair. So when [CMS] looked at it, they couldn’t put it in K0005, because the frame is going to need to weigh more than 30 lbs. if it’s going to accommodate a 650-lb. patient. The fact that the frame weighed more than 30 lbs. excluded that code from being an option, and so they said based on how much the chair weighs and the patient weight capacity, it’s a standard extra-heavy-duty manual wheelchair. It’s no longer a purchased option that it was under K0009; it would now be a capped rental, included in Round 2 of competitive bidding, which clearly it was not when the bids went out.

“You look at that and think, ‘What supplier would ever provide that sort of product under capped rental, and especially in the competitive bidding program, where the reimbursement for that code is so significantly less than the fee schedule?’ It will not happen.”

Lippes says he was told in a meeting that CMS indeed wanted to make sure access to former K0009 chairs wasn’t hurt — but questions how the agency can effectively monitor such a small number of products.

In 2011, Lippes notes, 6,500 K0009 chairs were supplied in the United States. Medicare paid for only 307 of them — though the agency’s elimination of the K0009 code will also carry over to other payors.

“You’re going to make a decision that’s going to hurt the independence of all Americans who need these products when only five percent of those people are Medicare beneficiaries?” Lippes asks. “Ninety-five percent of the people you’re going to hurt through this decision are not Medicare beneficiaries, yet you’re still going to make this decision? CMS simply must consider beneficiaries of private insurers when making decisions like this.”

Anderson notes, “The folks that they’re monitoring, it’s such a small group that how much are they really going to hear back? There are thousands of people who are going to be aff ected this year, of which they’re going to see a very small percentage of them, even if [CMS] is monitoring it.”

Hostak agrees that CMS, even in eliminating the K0009 code, does not believe it’s causing or that there will be an access issue.

“They’re not saying, ‘That’s not important for you to have,’” she says, referring to a high-performance manual chair for a client such as Anderson. “They clearly would say, ‘You’re 6'9", you’ve got to have that. There’s nothing available that’s an off -the-shelf product that’s going to meet your needs, so we acknowledge that.’ Their problem is, ‘We don’t think you need a unique code for that to happen, and we think we’re paying too much for that item under the K0009 code. Oh, and by the way, we often use a different definition for custom than what was originally placed in the Social Security Act, because we had the option of either using Medicare’s definition of custom or the definition of custom in the Social Security Act. We chose to use our own, and based on our own definition, you’re not custom. Custom means you have to be so unique that you can’t be grouped for pricing, and clearly, you have an order form with a price on it, so it must be able to be grouped for pricing.’”

Underscoring the Need for a Separate Benefit

While the correlation certainly wasn’t intentional, the official elimination of the K0009 code happened at about the same time the industry was getting very good news: H.R. 942, the House bill that would establish a separate benefit category for complex rehab technology (CRT), would soon be joined by a companion Senate bill introduced by Sen. Chuck Schumer (D-N.Y.). (At press time, the bill had not yet been introduced.)

Don Clayback, executive director of NCART, was in the work group that met with CMS about the K0009 elimination.

“We’d been working on that K0009 issue since last fall, and unfortunately we didn’t get what we wanted,” he says. “But I think it does underscore the whole challenge, which is to have policymakers recognize that it’s specialized equipment, and it needs to be recognized as such. That is one of our main messages when I talk to folks: That our biggest challenge and our additional objective is really to educate people on what CRT is, who uses it, how it provided the benefits it produces. Because without that baseline education, you really can’t develop policies and coverage and payment around these products.”

While Clayback acknowledges the tasks on CMS’s plate, he also believes eliminating the K0009 code wasn’t the best way to address what CMS obviously considers to be a problem.

“We understand CMS has a challenge to provide coverage and payment for all sorts of healthcare services and products,” he says. “There has to be some structure, and they have to have certain policies and try to standardize as much as they can in terms of that process.

“The challenge, though, is to find the right balance, and in our opinion they’ve thrown this out of balance. We know we can capture the vast majority of products within the current coding structure. But at least historically, we’ve had this ‘other’ wheelchair code that covers those specialized wheelchair bases that just don’t fit into one of those other codes.”

Realistically, Clayback says, there will always be a very small percentage of people with disabilities who have such specialized needs that they need a more individualized strategy for their assistive technology.

“You need to take the approach that we’re going to try and compartmentalize as much as we can within already established codes,” he says. “But we also recognize that there is no way we can have a code for every single item. So once we’ve identified and coded, for example, 95 percent of wheelchair bases, we need to have another code or a set of codes that addresses these bases that can’t be grouped with other technology. If there’s similarity in terms of characteristics and how it’s applied, how it’s provided and the pricing and cost of it, you can group those things into individual codes. But where you have a lot of variance, where it doesn’t work for every wheelchair base — that was really the purpose of the K0009 code.”

Clayback said the work group tried to help CMS to find a solution short of eliminating the K0009 code.

“Our conversations with CMS were ‘That’s how that code has been used and has been working. If you have a concern about that, there are really two options. One, change how that code is being administered; or two, create additional codes that take those specialized products and properly segregate them.’

“The third option, which is the one they took, is the wrong option — which is to say, ‘We’re just going to take these items and we’re going to cram them into an existing code that might have one similarity, but we’re going to ignore the eight other dis-similarities.’

That’s really what our continued challenge is: To find solutions that meet a [CMS] concern, but that the solution or the change that CMS makes doesn’t undermine access.”

Ideally, Clayback says, CMS would be able to have a system streamlined enough to be efficient, but one that doesn’t artificially force products into inappropriate codes.

“CMS is sometimes limited in what they can do, so I’m not saying these solutions are easy,” he notes. “But the solution isn’t to do the wrong thing. The solution is to look at the options that are available and either pick one that doesn’t damage access, or change some of the system so you can have an option that works for everybody and doesn’t undermine access.

“You certainly don’t take all the wheelchairs and put them into this individually considered code. We have to have some sort of system where we can categorize the majority of those products. That’s why you have the K0005 wheelchair and the E1161 manual tilt-in-space, and you have the Group 3 power wheelchair category. There are certainly ways that you can address the vast majority of wheelchair bases and accessories. But in our minds, you’re always going to have that one other code that needs to be a catch-all for those low-utilized items that are important for people who have certain needs that can’t be met with one of those other chairs.”

Anderson points out, “The people that use this type of equipment absolutely need it to be functional. It’s not like they can get around in another fashion. Their level of function, such as mine, is dependent on that. And with that small investment, you’re contributing to society versus taking from society. I think it’s a fundamental difference.”

This article originally appeared in the June 2013 issue of Mobility Management.

In Support of Upper-Extremity Positioning